Breast reconstruction using tissue from your back: an LD flap

This operation involves moving a large muscle (latissimus dorsi) and some overlying fat and skin from the back of the body. The flap and its blood supply are tunnelled under the skin just below the armpit. It is then put into position to make a new breast shape, with or without an implant. The operation is referred to as a latissimus dorsi flap, or LD flap. More medical information about an LD flap breast reconstruction can be found on the Macmillan Cancer Support website.

Some women said that, after talking to the plastic surgeon and breast care nurse, they decided to have an LD flap reconstruction. A few had immediate reconstruction because they didn’t want to ‘wake up after surgery with no breast’, while others said they didn’t like the idea of having to wear a prosthesis. Several said they preferred an LD flap to a DIEP flap, which uses muscle from the abdomen, because it was a slightly shorter operation. One woman felt rushed into making a decision about immediate breast reconstruction and said she would have liked more time to think about the various options.

Hilary is a married, retired secretary with three grown up children.
Ethnic background / nationality' White British

Going back to when I was told what I’d got to have done, the mastectomy and the alternatives, straight away I said reconstruction. I didn’t, because I just thought I can’t have a mastectomy and wake up and look at nothing. That’s what was frightening. That frightened me that did, I must admit. But even though some people have said, “Oh I couldn’t have coped with the reconstruction.” I said, “No, I’ve got to have that.” And as one lady said on the forum, “You go into hospital with two breasts and you wake up and you’ve still got two breasts.” And the astonishing part of it is, the breast you’re looking at is still yours because the skin there is still yours. It’s only the inside that’s, well it’s, that inside is still yours because it’s come from my back.

So it, yeah, it came from …

Mine came from my back. Yeah.

So you were given all the information from the breast care sister, and you took home all the information. How did you decide this is the operation that I want, from the back? Did you decide that or did they help you decide?

The plastic surgeon examined me and he said straight away, he sort of touched my back, the fleshy bit, “Oh you’ve got plenty there” he said. In fact, I think he said, “Oh you’ve got a good kilo there.” He says, “So that will be OK.” I was sort of hoping that I’d have it off my tummy because I’ve always had a big tummy but whether he thought perhaps, because it is a lot longer operation, so when he said that about my back I thought, well, you know, that’s what I went for.

And he showed you photos or pictures?

Yes he did. Yes he showed me photographs, yeah.

One woman said she was unhappy with pictures she’d seen of reconstructed breasts but found it reassuring talking before her surgery to a younger woman who’d had the same operation. Several said they would have liked to speak to other women who’d had breast reconstruction before deciding which sort to opt for. After surgery, one woman met two such women, which she found extremely helpful because they could compare experiences.

Di is a married teacher with two adult sons.
Ethnic background / nationality' White British

One of the books I sent for or, yes I sent from one of the charities about reconstruction, also showed really quite alarming pictures of breast surgery reconstruction, they were surgical pictures or medical pictures. They weren’t pictures of fit women with taut, bronze skin showing they were proud of their bodies even though they were scarred. They were women of all shapes and sizes with sort of cream and purple skin and bruises and fresh stitching, and I thought that was appalling.

And so they actually, I can remember saying to my husband “Well you look at this book because it just turns my stomach.” And that was the stage I was at really, I just found the idea of surgery dreadful.

So a counsellor was very good in getting me to visualise more positive images than that and helping me get things a bit more in proportion about what the final result would be like. And in fact the final result was far less scarring, on my front anyway, than I would have envisaged, even though I’m a bit perhaps uncomfortable because I’ve got quite a big scar across my back. But, you know, that’ll improve and I’m not very far from the surgery yet so that will come down to nothing.

It was a reconstructive ward, all sorts of things were happening and there wasn’t anyone else in as far as I knew with the reconstruction. They were talking about one other lady in the side ward, because she was in that ward I never met her. And she’d had I think a different form of reconstruction.

Funnily enough there was one lady who had sought me out who had been in the neighbouring bed when I was admitted and she returned to a clinic and asked to see me. And she’d had a reconstruction two years previously and she’d just been in for a little bit of tweaking I think on the day I was admitted. And she sought me out, it was terribly kind of her, and very reassuring to say that it would be all right in the end really. And she was much younger than I am and vigorous and fit and she helped redress the balance really given the pictures I’d seen in the awful book about reconstruction. And she was attractive and obviously being fit mattered to her too. So that was very helpful and she gave me her phone number, so that was nice.

Yes. Did you phone her?

No, but I’m going to [laughs].

Breast reconstruction using muscle, fat and skin from the back, is a major operation and needs a hospital stay of at least several nights. Using a flap from the back generally gives a lower risk of complications than using a pedicled flap from the abdomen, but an implant is often needed. Some women talked about how they felt when they came round after surgery, several saying that, at first, they had a stiff or sore arm and did exercises to keep it mobile. Many said they had support from family when they first came home and were careful not to lift heavy objects or over-exert themselves physically. One woman said a friend of hers was having a similar operation at the same time as her and they supported each other.

Di is a married teacher with two adult sons.
Ethnic background / nationality' White British

I wasn’t prepared for the amount of arm pain I’ve had, no one actually told me when I woke up from the operation, my arm was a lot less painful than it is generally now. And I wasn’t prepared for how long it would take for my arm to be able to move really freely without pain. I’m still not at that stage yet. And fairly annoyed at still having to take quite strong painkillers for it because I don’t like pills. I don’t like having to rely on pills.

But, on the whole, I believe that its going to go and I believe I will get back to fitness and I will find ways of compensating for the bit of lost muscle, its not going to affect me too much. Because what I’ve been really anxious about doing again is yoga, and you need such a good range of movement for that. And even though in normal life, the bit of muscle they took doesn’t matter but in yoga it does because you need control and strength and flexibility and that bit of muscle had a purpose. So I feel threatened about that but I feel I’ll work at redressing that.

A few of the women we spoke with said that they still had pain and discomfort across their arm and other areas of the body several months after surgery. One had minor surgery later to treat this and another was hoping to have some minor surgery.

Ann is a married careers advisor with one adult child.
Ethnic background / nationality' White British

I have been unlucky with my LD flap I think because I was in quite a lot of pain and I don’t think people believed me actually. I know that sounds awful but that’s how I felt, people didn’t believe me. I went to a physio for two, privately I went to some physio for two sessions several times because I just felt everything was pulling across the front. So I had the operation in February, and this is two years ago now, and people, you know, if you ring up anybody or talk to your GP, I think four to six months they expect a few aches and pains, all right, get on, you know, no problems. But this was going on October, November and I was still, and in fact it was the physio that said to me in the end, she said, “Well, I can’t stop that. You know, I can’t, when all this exercise, it’s something that’s in…” And that, I did get myself in a state because I was in quite a lot of discomfort and I used to wake up every morning feeling exhausted. And I was getting emotionally all wound up as well.

So when I went back for my yearly check, I was pretty desperate actually. I was feeling but, and this is where, I don’t know if I want to say all this really but it was, I got very upset because I felt I had to be very assertive in there and say, you know, apparently lots of women have sort of various party tricks my surgeon called them. And I was just so angry, it was not a party trick. I was, you know…But anyway, he did offer me, offer to cut the tendon. So that was a year, well no, the tendon was cut last June so that was, but it took me a few months to get round to deciding I had to do it, I was getting so, I really was getting very down actually. I was because I couldn’t see a way out. I felt this was, and in the meantime my dad died and I had three or four months that was pretty, you know, going back and forward. It was just, OK, it’s all right. But, you know, looking back, it was a tough time.

So when I was ready I went back and I said please could, I’d like the tendon cut. But I am, you know, I was a state. I don’t reckon, so by this time I really almost got to a stage where I had a phobia about going back. But it was a different experience going in on a weekday, I have to say. The staff, you know, you don’t feel that there were people that were talking to you while you were waiting. The whole experience was different. And I also knew, of course, it wasn’t such a major operation. I knew that. I was so, so hoping it would make things better. So, you know, that’s what happened.

And I did go in and I was, I could feel relief immediately he did it because I had, used to get this great tightness right across my chest. I couldn’t breathe sometimes, especially at night. So it was a great relief and I did thank him very much and, you know, he’ll quote that he went in and said you know I felt like a new woman. I did. But unfortunately, as far as I’m concerned, I still have a lot of movement across my chest. I still have, and to be fair to my surgeon, he did say probably a few months in to when I first went in there that you know, if this movement was still there the nerve would have to be cut.

So I don’t know whether cutting the tendon was supposed to sort it all out or whether that was just part of the procedure but, you know, when I went back sort of four or five months after the operation that was cutting the tendon, I just felt that I was still wasn’t happy, I couldn’t, still feel it moves. I can feel it now all the time. There are certain things I do that it really gets aggravated.

Have you been back to mention this?

Yeah, yeah, I’ve been to see my surgeon but in the meantime by GP sai

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Profile Info

Age at interview:

48

Sex:

Female

Age at diagnosis:

47

Background:

Kath is divorced and living with her partner. She is a sales manager with three children.
Ethnic background / nationality' White British

From day one I was told to get my arm above your head. You read on the BCC site, you know, get your arm right round the back and do all these things. So I was keen obviously to get better and get back to fitness if you like and for everything to heal properly. So I did exactly what they said. Day three they discovered I had this nerve damage and that was only, again you don’t know what to expect. I mean, I originally had nerve damage right down my leg. Nerve pains, you know, just like, it’s like electric shocks and like stinging and burning goes on, you know. Like jabbing. As if somebody’s pricking you with hot needles kind of thing. You know. And it was, you know, the surgeon had come in and how was I? And I said, “Oh, you know, I feel fine.” And this was, of course you’re getting all the jabby pains going on with everything healing in there as well. But, I said, “But I can’t understand why have I got pain…” I had, right round my bottom and where I have it all the time is here. But right round my bottom I had it. Right down to my privates, here. I had kind of like a numbness round there. My back felt very, very strange. It was so swollen I guess and kind of numb. And I’ve still got numb areas on my back. But I also had all these pains going down my leg. But they’ve gradually lessened. And I thing the gabapentin has helped a lot. It’s a nerve painkiller, I guess it would be. I don’t know. It sorts out the nerves a bit.

Anyway, so it’s been a lot better since I’ve been on that but I still, a couple of nights ago, because I’ve done a bit of cleaning or whatever, I end up with ice packs here and on my back sometimes, you know, it gets that sore. Just to numb it, it feels better [laughs].

Yeah. And what are they going to do now. You mentioned you’d had more surgery.

I see my surgeon on Tuesday evening and I should be in again fairly quickly. What’s happened is I had indentations appeared about six weeks. And apparently that’s quite common. Because I do have a small implant in as well. And I saw the breast cancer care nurse on the Friday and I said, you know, she says, “Oh come up and I’ll have a look.” And she said to start massaging it. Now I’d not been told that before at all. So I was massaging it, you know, with the cream and by Sunday evening I’d, you know, started massaging it and I thought, “Well that’s really quite sore there,” you know.

And when I looked down I thought, “God that looks really strange.” Because this was all caved in here. And instead of just having a couple of little indentations here that looked really quite dark, the whole thing was dented in here sort of thing, you know. And seemed to have moved across. So I phoned and they said to come in and see [the surgeon] on the Tuesday evening, which I did. No, the following Tuesday, it was like a week and a bit later. So instead of going at my three-month assessment I went at two months. And he just took one look at it and he says, “Yeah,” he says, “the muscle’s pulled away. The back muscle’s pulled away from the chest wall muscle. So we’re going to need to reattach that.”

Right, so how …

But he said he wanted to wait until everything had settled down, because I’ve had a lot of contracting. I think, you know, I was quite athletic in my youth and dancing and things like that. And, even now just walking, it’s constantly, jump, jump, jumping. It still thinks it’s a back muscle. You know. So I don’t know if I’ve been given the right physiotherapy. I mean I’ve got a list like this to

One woman said she couldn’t have immediate reconstruction because, after her mastectomy, there was a possibility she would need radiotherapy. She had reconstructive surgery six months after her mastectomy and was glad not to have to wear a prosthesis any more.

Patricia is a married clerk with two grown up children.
Ethnic background / nationality' White British

I had the mastectomy in the February and I had my reconstruction in the August. I think it was a long time and if, but I’d already had two general anaesthetics in a very, very short time, so it was probably a good idea for me to wait.

Did you use a prosthesis or anything in between times?

Yes, I had a prosthesis. And my husband and I had a trip to China and that was so uncomfortable, but, oh it was just so hot, so sticky, and I really, really was looking forward to my new breast. And we came home from China and two weeks later I had my reconstruction. And it was great. Came back with no bugs this time.

How did you feel in between that time? When you were using the prosthesis. How did you feel in terms of your own body image, which other people have talked about and a lot of people also talked about how they felt about not having their breast there any more.

I really did not like walking into the bathroom and seeing myself with just one breast. That was horrendous. And also because of my various health problems, I can’t wear short skirts. I wear very long ones to cover up some problems I have with my leg, and then I was having to wear high necked tops because if I wore a V-neck top the prosthesis fell forward and you could actually see the scars. And I found that very, very frustrating that I couldn’t just get up in the morning and put on what I would like to wear, I had to think about what I was wearing.

And at one point on my trip, when I was in China I realised that the top I was wearing was gaping slightly, and so you know I was hunting around for safety pins, I felt very, very conscious of it, but balance wise it looked okay, you know, when you’ve got your clothes on, it did look alright. And the breast care nurse spent a lot of time making sure that I did look well balanced, probably more so than I do with the reconstruction as it is at the moment.

An LD flap operation leaves scars both from where the skin and muscle flap is taken, and on the reconstructed breast. The scar around the reconstructed breast is oval and the scar on the back usually goes straight across (horizontally), so a bra will generally cover it. Sometimes this scar is more diagonal, which can make it more difficult to cover with a bra but it could be covered with a swimsuit. Women also talked about how they felt about their changed body image.

Di is a married teacher with two adult sons.
Ethnic background / nationality' White British

When you did look at your surgery, your reconstruction, did you feel quite pleased that it wasn’t as bad as you expected?

It wasn’t as bad as I expected. And it was nowhere near as bad as I expected originally. Technically I think its miraculous, I think its simply amazing how they do it and what can be done. Personally, well I’ll just have to wait and see because its not settled yet in to the position that it will finally drop to, the tissue hasn’t really spread, I won’t know until 6 months how that’ll look. And I can’t imagine I’m going to complain, its certainly good enough.

But they told me all along that they didn’t think, even though I had very small breasts, because I’m quite slight, they said all along they didn’t think they would be able to make the other breast as big as the existing one. And so I’ve been prepared for that. In fact they found much more tissue than they thought they would, so what I have is a breast slightly bigger than the other one which is not something I’d ever dreamed of [laughs], it will settle and probably shrink over time, so that’s probably helpful.

But at the moment it means that there’s obviously a mismatch even though in clothes I’m fine, in the mirror its odd. And the, and it does, I think the most, worse than the appearance is the texture. They told me that this breast would be harder than my other breast because it would be using quite a lot of muscle which is a different texture to breast tissue, and it is much harder and much lumpier. I did, I thought it was going to be a bit harder so it does have a very different feel to the other breast.

An LD flap reconstruction generally has few problems and can make a small or moderate size breast very well. However, it cannot always match a very large breast. Some women with large breasts had a breast uplift procedure (mastopexy) or reduction of the other breast at a later time, to get a good match. A few also said they planned to have nipple reconstruction (see Nipple reconstruction).

Hilary is a married, retired secretary with three grown up children.
Ethnic background / nationality' White British

There is a little bit of scarring and I was told that straight away. Because the breasts that I’ve seen don’t look quite like mine but, as I said, the one, Alex her name was, she did say to me, “Yes Hilary, there is going to be a bit of scarring but don’t worry about it.” Which I didn’t. But I honestly think if she hadn’t have told me I might have gone a bit, you know. And then when I saw [the plastic surgeon] on the 31st of January, he said, “Yes, there is scarring there but don’t worry about it. I can put that right for you.” So he can do that cosmetically by the sound of it. Plus I’m going to have a new nipple put on as well. So, as I said, again, because I was told, I wasn’t left, I felt quite at ease with it, you know.

Yeah. And you’ve discussed with him that you’re going back, are you, to have the other breast matched with that one?

Yeah.

Yeah. And when they did the surgery, did they ask you then about matching the other one?

Yes. I, yes before, well before the surgery. My very first visit I saw [the plastic surgeon], he discussed that.

Yeah, so you knew then …

Yeah. That was my choice. I needn’t have it done if I don’t want to. But, as I say, I’m going back to see him the 31st July where we will discuss all this then.